14-00000

104-10129-10002 | 2025 RELEASE UNDER THE PRESIDENT JOHN F. KENNEDY ASSASSINATION RECORDS ACT OF 1992] .

rs

“e etme,
a ee eee “
c - . =. if ~

:  ——y
OO NOT USE THIS SPACE
+

THIS DATE (Fill In)

~

PERSONAL HISTORY STATEMENT

AUGUST 31, /F6/

- Answer all questions completely or check appropriate box. If question is not applicable, write “NA”. Write “Un-
known” only if you do not know the answer and it cannot be obtained from personal records. Use blank Space at
end of form for extra details on any. question for which you have insufficient space.

2. Type, print or write carefully; illegible or incomplete forms will not receive consideration.

3. Consider your answers carefully. Your signature at the end of this form will certify to their correctness. Careful
completion of all applicable questions will permit review of your qualifications to the best advantage.

SECTION | GENERAL PERSONAL AND PHYSICAL DATA
[EES BAME Cast Firat Micate) 1 [SEX

YODRIGUEZ , EMILIa Amercce; 35 yenes Paueyrud hme pee
. 6. COLOR OF EYES 7. COLOR OF HAIR 8. TYPE COMPLEXION 9. TYPE BUILD
tow! SO ths. ROWN | BLACK “AuUDD MEDIUM
10. SCARS (Type end Location) .
NONE
11. OTHER DISTINGUSHING PHYSICAL FEATURES
NONE

12. CURRENT ADDRESS (No., Street, City, Zone, State and Country)

13, PERMANENT ADDRESS (No., Street, City, Zone, State and

F36/ S.W.°179 ST. 930) SwenppsT, COME:
., . ! : ‘ (CE dar S-8341
“PERRIVE S7, FLA. PERRINE $7, FLA. ;

A

14. CURRENT PHONE NO. 15. OF FICE PHONE NO. & EXT. 16. LEGAL RESIDENCE (State, Territory or Country)
f i 5
Cdn S-§ 34s; NA. FLORIDA, U.S. 8.
17. NICKNAMES 18. OTHER NAMES YOU HAVE USED
NONE

[4UGENIc  GoNnzALEZ,!

19. INDICATE CIRCUMSTANCES (Including Length of Time) UNDER WHICH YOU HAVE EVER USED THESE NAMES.

Fike BPRIL 1760 To PRESENT (¥ ARVANA ,CHBA AND MIAMI FLG. as UNDERCOVER NAME

20. 1F LEGAL CHANGE, GIVE PARTICULARS (Where and by What Authority). .

[SECTION tl POSITION DATA
1. INDICATE THE TYPE OF WORK OR POSITION FOR WHICH YOU ARE APPLYING

(CONTRACT AGENT |

\

(You will not be considered for any position with a lower 3 DATE AVAILABLE FOR EMPLOYMENT x
entrance aalary), 9,600.06 ‘COM TRRET ALREADY SIGWED,;

. 4. INDICATE YOUR WILLINGNESS TO TRAVEL
7

5. INDICATE YOUR WILLINGNESS TO ACCEPT ASSIGNMENT IN THE FOLLOWING LOCATIONS (Check (X) each item applicable)

|] WASHINGTON, D.C. bd ANYWHERE IN U.S. x CERTAIN LOCATIONS ONL Y (Specify):

2. INDICATE THE LOWEST ANNUAL ENTRANCE SALARY YOU WILL
ACCEPT

OUTSIDE CONTINENTAL U.S.
6. INDICATE WHAT RESERVATIONS YOU WOLD PLACE ON ASSIGNMENTS OUTSIDE THE WASHINGTON, D.C. AREA.

ADEQUATE PAY AVD LIVING CONDITIONS OR
S&LF AND FAMILY

Fors 444 use Previous EDITION.


14-0000

SECTION In < ° CITIZENSHIP

-2- :
<n
1. DATE OF AIRTH 2. PLACE OF BIRTH (City, State, Country)

3. PRESENT CITIZENSHIP (Country)
Say. 27/928) HAVANA. CuBR

4. CITIZENSHIP ACQUIRED BY fs. DATE NATURAL- | 6. NATURALIZATION CERTIFICATE NO.
| femme | [wanmace [XJotner (Speci yprueg.| Decentg er 1S} 1944 HEMIFATS }

7, COURT ISSUING NATURALIZATION CERTIFICATE 8. ISSUED AT (City, State, Country)
-S.Disrarcr Count of Ensrern Dist. of Lousstaw New Boe EAN S LA .-

8. HAVE YOU HELD PREVIOUS NATIONALITY 4" IF YES, GIVE NAME OF COUNTRY

[Xives_ | ne Cu GA

11, GIVE PARTICULARS CONCERNING PREVIOUS NATIONALITY.

CUBAN BY BIRT Hf

\. ARS
12. HAVE YOU TAKEN STEPS TO CHANGE yes | 13. GIVE PARTICUL

PRESENT CITIZENSHIP
X[ No W.A.
14. IF YOU HAVE APPLIED FOR U.S. CITIZENSHIP, WHAT 1S PRESENT STATUS OF YOUR APPLICATION (Firat Papers, Etc.)?

N. A.

15. DATE OF ARRIVAL IN U.S. 16. PORT OF ENTRY 17. ON PASSPORT OF WHAT COUNTRY
UNE SC , [FE MIAMI, FLA. SWISS PROTECTIVE Passport
16. LAST U.S. VISA (No., Type, Place of Iseue) 19. DATE VISA ISSUED
RESIDENT _ ¥.5. EMBASSY IN HAVANA, CUBR Nov. /F4¢Z
SECTION IV EDUCATION
1. CHECK (X) HIGHEST LEVEL OF EDUCATION ATTAINED

|| LESS THAN HIGH SCHOOL GRADUATE OVER TWO YEARS OF COLLEGE - NO DEGREE
|| HIGH SCHOOL GRADUATE BACHELOR'S REGREE

|| TRADE, BUSINESS, OR COMMERCIAL SCHOOL GRADUATE GRAOUATE STUDY LEADING TO HIGHER DEGREE
a 7
|| TWO YEARS COLLEGE OR LESS . Ds MASTER'S OEGREE |_| DOCTOR'S DEGREE

2. ELEMENTARY SCHOOL

1. NAME OF ELEMENTARY SCHOOL 2. ADDRESS (City, State, Country)
COLEGIo DE LA SALLE! HAVANA , CUBA
3. DATES AT TENDED (From-and-To) 4. GRADUATE

Se . S93 76 Nov. FEZ : x] ves Two

1. NAME OF HIGH SCHOOL 2. ADDRESS (City, State, Cowmtry)

Néw @O¢lEANS , kR

3. DATES ATTENDED (From-and-To) 4. GRADUATE

Noy. (i420 Juve (245 (Xe SCS

1. NAME OF HIGH SCHOOL 2. ADORESS (City, State, Country)’

4. COLLEGE OR UNIVERSITY STUDY :
REC’ HOURS

NAME AND LOCATION OF COLLEGE OR UNIVERSITY

) 4... SECTIONIV CONTINUED TO PAGE 3 ed

14-0000

@ | SECTION V FOREIGN LANGUAGE ABILITIES e

-

, “*" SECTION IV CONTINUED FROM PAGE 2

5. {F A GRADUATE DEGREE HAS BEEN NOTED IN ITEM 4 WHICH REQUIRED SUBMISSION OF A WRI
OF THE THESIS AND BRIEFLY DESCRIBE ITS CONTENT UO REQUIRED SUBMIS TTEN THESIS, INDICATE THE TITLE
: &

Ft EPITETO EW LAS OBRAS DE BERCES (De wor REmemace Quer rerz é). A DETAILED:

STUDY OF THE MANY USES OF THE EeirHer iy BERCEO'S WORKS A (2TH cevrury weiter:
MELDING A CROSS - REFER ENCE SISTING OF Aik EPITHETS AS StlowNn IN HIS WRITINGS 7?

6. TRADE, COMMERCIAL AND SPECIALIZED SCHOOLS

a
Wf a

7. MILITARY TRAINING (FULL TIME DUTY IN SPECIALIZED SCHOOLS SUCH AS ORDNANCE, INTELLIGENCE, COMMUNICATIONS, ETC.)

8. OTHER EDUCATIONAL TRAINING NOT INDICATED ABOVE.

which you possess any degree EQUIV- FLUENT

. COMPETENCE - IN ORDER LISTED
(Liat below each language in
oe “ed

ALENT ADEQUATE | ADEQUATE]: Limit an an -
of competence. Indicate your To OBVIOUSLY FOR FOR Know. | Native |, PRO-
proficiency to Read, Write or NATIVE FOREIGN | RESEARCH] TRAVEL LEDGE ° LONGED
Speak by placing a check (X) FLUENCY COUNTRY IGeRCE

in the appropriate box(es).

plete fete tots te Tw Ts [a Tw Ts |

0 ee

tik XT XT ETE TTP

alii titi tT Xx TT 2S

Zriey | 11} TIT IT ELT XXX | BS

2. IF YOU HAVE CHECKED “*ACADEMIC STUDY’ UNDER *HOW ACQUIRED”, INDICATE LENGTH ANO INTENSIVENESS OF STUDY.
FRom (94% Yo 19S STUDIED THE RemtancE LANGUAGES AT THE GRADURTE

LEVEL

3. IF YOU HAVE INDICATED FLUENCY FOR A LANGUAGE HAVING SIGNIFICANT DIFFERENCES IN SPOKEN AND WRITTEN FORM,
PLAIN YOUR COMPETENCE THEREIN.
MN: 4.

4. DESCRIBE YOUR ABILITY TO DO SPECIALIZED LANGUAGE WORK INVOLVING VOCABULARIES AND TERMINOLOGY IN THE SCIEN-
TIFIC, ENGINEERING, TELECOMMUNICATIONS, MILITARY, AND OTHER SPECIALIZED FIELOS.

FAMILIAR wiTtg SCIENTIFIC Awd ENGINEERING “TERMINOLO G Y W SPANISH.

=_

5. IF YOU HAVE NOTED A PROFICIENCY IN LANGUAGE, WOULD YOU BE WILLING TO USE THIS ABILITY IN ANY POS!TION FOR WHICH
YOU MIGHT BE SELECTED? .
[Sd YES (_] No

14-0000

ne

-4-

‘SECTION Vi a GEOGRAPHIC AREA KNOWLEDGE AND FOREIGN TRAVEL

>
he List BELOW ANY FOREIGN REGIONS OR COUNTRIES IN WHICH YOU HAVE TRAVELLED OR GAINED KNOWLEDGE AS A RESULT OF
* RESIDENCE, STUDY UR WORK ASSIGNMENT. INDICATE TYPE OF KNOWLEDGE SUCH AS TERRAIN, HARBORS, UTILITIES, RAIL-

KNOWLEDGE ACQUIRED BY

ORK
TRAVEL /STUDY | ASSIGN-

ROADS, INDUSTRIES, POLITICAL PARTIES, ETC.
se

DATES OF
NAME OF TYPE OF ; DATES AND
REGION OR COUNTRY SPECIALIZED KNOWLEDGE RESIDENCE PLACE OF STUDY

w
MENT

Econ ‘ Weeine hactag Lipsy 19, |
Comomic. ¢ SOCIAL uCTUK
B A CMPLER E~ i Pee TarteWn ISS VIEL M.A. a™

IM

X

LE
_
x

“To worle As Assis lay t Disheick Mawgyen foa Coukna CLeclere Co. m chae <2
of then Havawn Office, av Havant Cagy, Late Rembived iw Cuba pacer Mach Geo
°f & Cffice, mm Havawa Cuba. Se ihe Caracal L ZH.
3. UNITED STATES PASSPORT NUMBER AND EXPIRATION DATE, IF ISSUED. . a "
s WEMOGS GE Expinet> Seph 2 (F€0 (wer genewed)
SECTION VII TYPING AND STENOGRAPHIC SKILLS
"TYPING (pay | 2. SHORTHAND (wpm)
SO NA. | [erece | [sreeownitine | [stenorves | [otwen (Speci:  —*d
2. INDICATE OTHER BUSINESS MACHINES WITH WHICH YOU HAVE HAD OPERATING EXPERIENCE GR—ERAINING (Comptometer,

Mimeograph, Card Punch, Etc.). -
MIMEOCGRAPH , ADDING MACHINE, CALCUL ATOR , DICTATING MACHINE .

SECTION VIII SPECIAL QUALIFICATIONS

.1. LIST ALL HOBBIES AND SPORTS IN WHICH YOU ARE ACTIVE OR HAVE ACTIVELY PARTICIPATED. INDICATE YOUR PROFICIENCY
IN EAC

ACH.
FIS, PP ; : ;
MING, HUNTING, SWIMMING (Good UNDERWATER RESISTANCE ) PloTOGRA PHY
(BLAck # wHiTE AND Cocoe) | Musical p ; /

Bow Iiy

Wa Chess.

Avega C (MY ALL OF THe Rgove .
1,

“Ay SEVEROL INSTRUMENTS GY EAR), FLYING
7

2. INDICATE ANY SPECIAL QUALIFICATIONS RESULTING FROM EXPERIENCE OR TRAINING WHICH MIGHT FIT YOU FOR A
PARTICULAR POSITION OR TYPE OF WORK.

Tegcuine Aap ROMS TRATIVE FRPERIENCE SECURED AT THE UnivERS: Ty

LECEL AWD IN FOREIGN TRADE UANAGEMENT PESPECTIVELY. Akso

CRPACITY Te CARRY eur WOE PENDENT PESERR CH AT THE GeRapurgre LEVEL.

3. EXCLUDING BUSINESS EQUIPMENT OR MACHINES WHICH YOU MAY HAVE LISTED IN ITEM 2, SECTION VII, LIST ANY SPECIAL
SKILLS YOU POSSESS RELATING TO OTHER EQUIPMENT AND MACHINES SUCH AS OPERATION OF SHORTWAVE RADIO (Indi-
cate CW apeed, sending end receiving), OF FSET PRESS, TURRET LATHE, SCIENTIFIC AND PROFESSIONAL DEVICES.

FAMILIAR WITH GENERAL SClEVTigve APPARATUS AS MAY BE PRESENT

echeph fe wne Tay .

/W A MEAL ReSERCCH “ABeRATORY Beckman

(Div ove VEOR RESEARCH AT TULANE MEDICAL Stu20L))

SECTION VIII CONTINUED TO PAGE 5

" . ( (


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» SECTION VIII CONTINUED FROM PAGE 4

. ARE YOU NOW OR HAVE YOU EVER BEEN A LICENSED OR CERTIFIED MEMBER OF ANY TRADE OR PROFESSION, SUCH AS PILOT,

ELECTRICIAN, RADIO OPERATOR, TEACHER, LAWYER, CPA, MEDICAL TECHNICIAN, ETC.?

Bres [No

. IF YOU HAVE ANSWERED “YES* TO ABOVE, INDICATE KIND OF LICENSE AND STATE_ISSUING LICENSE (Provide License Registry

Number, if known).

Student Blot Ceatifieate Wt S- 293957

» FIRST LICENSE OR CERTIFICATE (Year of Isaus) 7. LATEST LICENSE OR CERTIFICATE (Year of Issue)

4-18-S¢ MA-

. LIST ANY SIGNIFICANT PUBLISHED MATERIALS OF WHICH YOU ARE THE AUTHOR (Do NOT ‘submit copies unless requested). INDICATE

THE yr UELICATION DATE, AND TYPE OF WRITING (Non-Fiction or Scientific articlea, General Interest aubjecta, Novels, Short .
tories, Etc.), .

N.A.

» INDICATE ANY DEVICES WHICH YOU HAVE INVENTED AND STATE WHETHER OR NOT THEY ARE PATENTED.

WA.
. LIST PUBLIC SPEAKING AND PUBLIC RELATIONS EXPERIENCE.

IN COLLEGE AND AS 4 TumwR ExEcuTwE W FOREIGN TRADE

. LIST ANY PROFESSIONAL, ACADEMIC OR HONORARY ASSOCIATIONS OR SOCIETIES IN WHICH YOU ARE NOW OR WERE FORMERLY
A MEMBER. LIST ACADEMIC HONORS YOU HAVE RECEIVED.

Phi he Lola , Nahowal Hower Seciely of Ronanee Hawgnases.

Aweqrcay Associatin of Teachers of wish oud Bak ; e.
Crenduate Sche Bas Mis of fered 4 7 the s of howt sane sad! Tabane Unweesi ly. :

Cumd€R wey Z Dr five YEqas OF GRAD~ATE wogc) ! 7
Howonney MEV Tions AWD MEDALS, .

NOTE: (LIST LAST POSITION FIRST.) Indicate chronological history of employment for past 15 years. Account for all periods
including casual employment and all periods of unemployment. Giveaddress and state what you did during periodsot
unemployment. List all civilian employment by a foreign Government, regardless of dates. Incompleting item 9, “De-
scription of Duties” consider your experience carefully and provide meaningful, objective statements.

2. NAME OF EMPLOYING FIRM OR AGENCY

(CENTURY ELECTRIC COMPANY!

c E é (74 {v1
4. KIND OF SUSINESS f v
MAVAFACTURER OF MOTORS. GENENB TOES » ETC. Aff “a fe: f pox fi

as
Assifort Disracy MAINGE Ls ooo ren mba ty haps

%. DESCRIPTION OF DUTIES Toa PRongre AND Shyer THE SALE SA CEvr’R MoTORS, GEV ERG TORS,
4VD RECATED §Qia Pheer in THE TERA re RY 2f CUA, Bb To WOPERRTE mw COLLECT ions
WHEY NECESSARY, T2 IANAGE THE HAVANA WSTRCT Sag és Otte 1 FULL PESPENSA BIT Y (NV

HE ABSENCE of THE Dxsrerer~ MGR. Tt KK ASTER THE a PIRES OF Cay tity ELEC. Ce) NNER
10, REASONS FOR LEAVING 7

—_ PRESENT Com Tiows (W¥ CuBR Med RECEPTAYCE) ASSIGNMENTS
: . re - - : :
OS Pevcep. Ween (Vv CXEA FoR C.I.A. °

SECTION IX CONTINUED TO PAGE 6

14-0000

j 1. INCLUSIVE DATES (From and To - By Mo. and Yr.)

3. ADDRESS (No., Sereef, City, State, / f

a ~ . -~
ST CHARLES : WEW ORLE
S. NAME OF SUPERVISOR

4. KIND OF BUSINESS : f
veces de ek Ee

6. TITLE OF JOB 8. CLASS. GRADE (If Federal Service)
0 ; {
Geaduate Asst [s geo [PER Ayo td byl

9. DESCRIPTION OF DUTIES
TEACHER oF BEGINNER had INTERMEDID-TED SPANISH a THE
CoLheGk LEVEL. 1b ASSIST Wingy Reis TRATI04" BND DECARTAMENTAL Funeri ons,

10. REASONS FOR LEAVING

Je ACCEPT ABOVE PosiTion

+. INCLUSIVE DATES (From and To - By Mo. and Yr.)

SuUWwe /F

3. ADORESS(No., Street, City, State, Country)
(ZW TERWA TIONAL TRADE MART NWEWw Crt EAWVS , LA, 4-S-
ECTER

4. KIND OF BUSINESS S. NAME OF SUPERVISOR
LANGURGE  SCHeOe My. HALL, Dew ;
6. TITLE OF JoB | _7. SALARY OR EARNINGS 8. CLASS, GRADE (If Federal Service)
THo FESSOR . A

8. DESCRIPTION OF DUTIES To TEACH THE SPAMS tf LAN. 4 BERLITZ ME THoDd on

10. REASONS FOR LEAVING

Te ACCEPT #FEOVE RSITION AND PARSU
AV ADVANCED DEGREE

1. INCLUSIVE DATES (From and To - By Mo. and Yr.)

JAW: /4F4F — 4 19

3. ADDRESS (No., Street, City, State, Country)

ANE Ave. a Aus Lf. . 5.4.

{Tac a z A
4. KIND OF BUSINESS 5. NAME OF SUPERVISOR ete et
; aes oo
MEDICAL Stspoe De. Wee
6. TITLE OF JOB ®. CLASS. GRADE (If Federal Service)
‘ —
Metical Kestwtch fechuidtan $ 200-70 |PER pyera |

9. DESCRIPTION OF DUTIES | \ oe
WY CHBRGE 4F SPECTRO pile TOMETRIC AWALYSIS WM THE CARDIO —
VASCULAR RESERRCY “4A GBORBTO ay.

2. NAME OF EMPLOYING FIRM OR AGENCY

_TALANE UNIVERSITY MEDICAL SCHooL
TY

10. REASONS FOR LEAVING

CONCLUSION OF RESEAR CY

1. INCLUSIVE DATES (From and To - By Mo, and Yr.) 2. NAME OF EMPLOYING FIRM OR AGENCY
3. ADDRESS (No., Street, City, State, Country)

4. KIND OF BUSINESS 5S. NAME OF SUPERVISOR.
6. TITLE OF JOB -- 7. SALARY OR EARNINGS 8. CLASS. GRADE (If Federal Service)
$ [Per |
,

r SECTION IX CONTINUED TO PAGE 7 -
rr


14-0000 boots. om

9. DESCRIPTION OF, DUTIES

10. REASONS FOR LEAVING
1. INCLUSIVE DATES (From and To - By Mo. and Yr.) 2. NAME OF EMPLOYING FIRM OR AGENCY
- ADORESS (No., Street, City, State, Country)
. KIND OF BUSINESS 5. NAME OF SUPERVISOR
. TITLE OF JOB 7. SALARY OR EARNINGS 8. CLASS. GRADE (If Federal

Service)

- DESCRIPTION OF DUTIES

10. REASONS FOR LEAVING
1. INCLUSIVE DATES (From and To - By Mo. and ¥r.) 2. NAME OF EMPLOYING FIRM OR AGENCY
3 ADDRESS (No., Street, City, State, Country)

4. KIND OF BUSINESS 5. NAME OF SUPERVISOR

6. TITLE OF JOB 7. SALARY OR EARNINGS B. CLASS. GRADE (If Federal
Service)

9. DESCRIPTION OF DUTIES

10. REASONS FOR LEAVING

IF PRIOR SERVICE WITH THE FEDERAL GOVERNMENT IS NOTED ABOVE, INDICATE THE
NUMBER OF YEARS CREDITABLE TOWARD U.S. CIVIL SERVICE RETIREMENT, iF KNOWN.

HAVE YOU EVER BEEN DISCHARGED OR ASKED TO RESIGN FROM ANY POSITION. Cres Bano
HAVE YOU LEFT A POSITION UNDER CIRCUMSTANCES WHICH YOU DESIRE TO EXPLAIN? Cres B<gJNo
IF YOUR ANSWER TO EITHER OR BOTH QUESTIONS !S “YES®, GIVE DETAILS


14-0000

SECTION X . MILITARY SERVICE
_ : 1, CURRENT DRAFT STATUS

1. ARES YOU REGISTERED FOR THE DRAFT UNDER TS) 2. SELECTIVE SERVICE CLASSIFI-
THE UNIVERSAL MILITARY TRAINING AND CATION “4 Fr

3. SELECTIVE SERVICE NO. .
SERVICE ACT OF 1948 (Ae,amended) 16-US-2§9- $3.
4. IF DEFERRED, GIVE REASON D

DIABETES MELL/ THs

2. MILITARY SERVICE RECORD
|. CURRENT AND/OR PAST ORGANIZATIONAL MEMBERSHIP

COAST |MERCHANT) NATIONAL/AIR NAT*L| FOREIGN ORGAN. OR MIL.

CHECK (xX) AS
MARINE | SERVICE (Specify):

APPROPRIATE

MARINE
ARMY NAVY CORPS

3. DATE SEPARATED FROM EXTEN

FORCES (Past and/current service)

6. TOTAL LENGTH A
jeans
7. RANK, GRADE or | Past reas CURRENT SERVICE 8. fSERVICE, SERIAL OR FILE NUMGER (If now serving, provide cur
/rent number)
9. PRIMARY MILITARY OCCUPAYIONAL T SERWICE CURRENT SERVICE
SPECIALTY (Mos or Designatog) AND TI
10. SECONDARY MIL. '* EEECURAR is Sten JONAL pereeevce SERVICE CURRENT SERVICE
SPECIALTY '* EEECURAR is Sten or Designgtor) AND
TITLE

11. BRIEF DESCRIPTION OF pt current service)

f

i
PAST SERVIG CURREMT SERVICE

ha oury/(Paet servicd) 4. TOTAL LENGTH OF EXTENDED ACTIVE OUTY IN U.S. ARMED

S. DATE ENTERED F ACTIVE DUTY IN FOREIGN MILITARY OR-

ACTIVE DUTY op

[RETIREMENT FoR ofavice’ a | _[unovenanoonips —OOSSSCS~S~S
[_[sELEAEE re nacre gory | [reviews ron fluor oangiey
P[RermenenT ronace | [Retinewent ron/pn|ficat oWsipiry — |

3. MILITARY RESERVE, NATIONAL GUARD AND ROTC STATUS

1, DO YOU NOW HAVE 2. ARE, YOU NOW A MEMBER, OF THE 3. ARE YOU NOW A MEMBER OF | [ves |

RESERVE STATUST

[><jno | ska
4. IF YOU HAVE ANSWERED “YES” TO ITEMS 1,2 OR 3 ABOVE, CHECK COMPONENT MEMBERSHIP BELOW
BER
PRavy fain once [fain wareouand [army noye | [ayerance neve
5. CURRENT RANK, GRADE OR [& Rang OF aPromrhewr w of TION DATE OF CURRENT RESERVE OBLIGA-
N

8. CHECK (x) CURRENT RESERVE CATEGORY ae ee,
9. PRIMARY MILITARY OCCUPATIONAL SPECIALTY (Mg D 10. SECOND ITARY OCCUPATIONAL SPECIALTY (Moa or Des-
LE.

12. CHECK (%) TYPE OF SEPARATION FROM ACTIVE DUTY
13, CHECK (x) COMPONENT IN WHICH YOU SERVED
fRecutar | | RESERVE (Including the National and Air National Guard) | | OTHER (Including AUS)
{ YES OTCT
NAT'L. GRD. OR AIR NAT'L. THE ROTC —-,
<[xo | P><Jxo |
mn ARINE CORPS | naTionateuang [1 COASTGUARD, | NAVY ROTC INDICATE ROTC CATEGORY NUM
RATE
ctive)| —_ [STANDBY(Inactive)| | RETIRED

nétor) AND TITLE ignator,

‘1. BRIEF DESCRIPTION OF MILITARY RESERVE DU

12, ARE YOU CURRENTLY ASSIGNED OR ATTACHED YES | 13. 1F you HAVE. ANSWERED "YES" TO ITEM 12, GIVE UNIT OR AGENCY
TO A RESERVE, NAT'L. GUARD OR ROTC TRAIN- AND ADDRESS
ING UNIT xX [No

14. HAVE YOU A MILITARY MOBILIZATION ASSIGN- Mi 1s. Feo HAY wie ial TO ITEM 14, GIVE UNIT OR AGENCY
Lx] xo | a

=
m
z
4
~

’
.

16. INDICATE TOTAL MILITARY SERVICE] YEARS 17. WHERE Aq OUR An/SERvt FE RECORDS KEPT
FOR LONGEVITY PURPOSES INCLUD-
ING ACTIVE AND INACTIVE DUTY

a

| rt = a RTO Ret in ee en ee ne a ener anaeepeensin eee

14-0000

1. ARE YOU ENTIRELY DEPENDENT ON YOUR SALARY? Dd ves imc
2. IF YOUR ANSWER IS “‘NO" TO THE AGOVE, STATE SOURCES OF OTHER INCOME

3. BANKING INSTITUTIONS WITH WHICH YOU HAVE ACCOUNTS

4. HAVE YOU EVER BEEN IN, OR PETITIONED FOR, BANKRUPTCY, Pa
S. IF YOUR ANSWER IS “*YES*’ TO THE ABOVE, GIVE PARTICULARS, INCLUDING COURT AND DATE(S)

WA.
6. GIVE THREE CREDIT REFERENCES IN THE UNITED STATES “
ome ADDRESS (Wow, Siroct, Gli Sat)

7. 00 YOU RECEIVE AN ANNUITY FROM fHE UNITED STATES OR OISTRICT OF COLUMBIA GOVERNMENT UNDER ANY RETIREMENT
ACT, PENSION, OR COMPENSATION FOR MILITARY OR NAVAL SERVICE? Cl Yes NO

8. IF YOUR ANSWER IS “YES"* TO THE ABOVE QUESTION, GIVE COMPLETE DETAILS

NA.

9. DO YOU HAVE ANY FINANCIAL INTEREST IN, OR OFFICIAL CONNECTIONS WITH NON-U.S. CORPORATIONS OR BUSINESSES; OR IN
OR WITH U.S. CORPORATIONS OR BUSINESSES HAVING SUBSTANTIAL FOREIGN INTERESTS?

(3 res Rt no (If anawer “YES*, tumieh details on acparate sheet.)

SECTION XII . : MARITAL STATUS : '
1. PRESENT STATUS (Single, Married, Widowed, Separated, Divorced, or Annulled) SPECIFY: mM G R ,

2. STATE DATE, PLACE, AND REASON FOR ALL SEPARATIONS, DIVORCES OR ANNULMENTS
\

WIFE, HUSBAND If you have been married more than once - including annulments - use a separate sheet for former wife or
OR FIANCE: husband giving data required below for all previous marriages. If marriage contemplated, fill in appropriate
information for fiance.
3. NAME . (Firat) : ; . . _ . (Last) oo.
“PRULINE )  . JuUANITA Ross _ RoDRiGUEz’ ;

4. STATE ANY OTHER NAMES EVER USED “INDICATE CIRCUMSTANCES (including length of time) UNDER WHICH ANY

; OF THESE NAMES WERE USED. IF LEGAL CHANGE GIVE PARTICULARS

. 4: (Where and by what authority). USE EXTRA SPACE PROVIDED ON PAGE !6
auth, CNIcKWAME SINCE Chit eod)

5. DATE OF MARRIAGE

OF THIS FORM TO RECORD THIS INFORMATION.
SUV (6.

7, HIS (OR HER) ADDRESS BEFORE MARRIAGE (No.,

39°C Obku
9 OATE OF DEATH 10. CAUSE OF DEATH

pe tiving
[<Tres [xo VA.

11. CURRENT ADDRESS (Give last addreaa, if deceased)

L$36/ Silos (16 St, ARERRINE $7.~ FLA

12. OATE OF BIRTH 13. PLACE OF BIRTH (City, Stato, Country)

SAN. 4,4 F _806GALUS A - SA,
SECTION XII CONTINUED TO PAGE 10

-9-

MA. °

aS.A.

14. CITIZENSHIP

“4.5.4.


14-0000 -10-

‘ . = + SECTION XH CONTINUED FROM PAGE 9

: . ry 14. IF BORN OUTSIDE U.S. OATE OF EWTRY 15. PLACE OF ENTRY
. WN. 4 . MN. 4 .
, : 17. -S. CIT! P| 18. wH City, St
16. FORMER CLTIZENSHIP(S)  [Couner(ies)7 7 DATE US. C TIZENSHI WHERE aa ity, State, Country)
WA. v4. ° A.

20. PRESENT EMPLOYER (Also give former ompto: if, or ife e de
19. OCCUPATION unemployed give last tws employers) mploye: Pouse deceased or

WA.

HOUSE WEE

2t. EMPLOYER’S OR BUSINESS ADDRESS (No., Street, City,

State, Country)

22. DATES OF MILITARY SERVICE (Froan and to - By Mo. and Yr.)

23. BRANCH OF SERVICE 24,

COUNTRY WITH WHICH MILITARY SERVICE AFFILIATED

N-A. LAE

25. DETAILS OF OTHER GOVERNMENT SERVICE, U.S. OR FOREIGN

Nw. FA.
. e PS ECTION AI ICSE FATTO DREN AND OTHER DEPENDENTS] xt CHILDREN AND OTHER DEPENDENTS
1. PROVIDE THE FOLLOWING INFORMATION FOR ALL CHILDREN AND DEPENDENTS
| —__Naws___[ ek aTionstiP [PATE AnD PLAGE oF euern [eifizenanie | —haonaas ———

- — “GIEl SWITE ST
|Euteto Ameaieo novRiauer I-R-) ale | aca. LELRINE S7, FLA.

36f Sh. 7
PATTI MICHELLE Rorkiquet) | PAUGTKE ;

etd a LA
; $360 SW. (79 ST.
ace zi 2 huh iy f PERRINE S72, ELK:

NDENTS (Including epouse,
parents, etep-parents, sister, otc.) WHO DEPEND ON

YOU FOR AT LEAST 50% OF THEIR SUPPORT, OR
CHILDREN OVER 21 yrs, OF AGE WHO ARE NOT

ILDREN jing step-
2. CH firenand, enitiptodt a Beet ARE

—
UNMARRIED, UNDER 2t YRS OF AGE,
AND NOT SEL F-SUPPORTEG.

; ; 3. DATE OF DEATH 4. CAUSE OF DEATH
ft. FULL NAME (Last-Firet-Midile) ; [ 2 twine |
wDRIGKEZ, Akwes7s NEPOLEON, Sires [no Wh. wae

INDICATE CIRCUMSTANCES (neluding length of fime) UNDER WHICH HE HAS

EVER USED THESE NAMES, IF LEGAL CHANGE, GIVE PARTICULARS (Where
and by what authority). USE EXTRA SPACE PROVIDED ON PAGE 16 OF THIS
FORM TO RECORD THIS INFORMATION, -

6. CURRENT AODRESS - Give imet editrese, if deceased (No., Street,

The Otleauvan fh -rtet ST
OE. Havas

0 et mere = 7
ca 10. IF BORN OUTSIDE U.S. -IJATE OF ENTRY
: Neu. /fér

12. FORMER CITIZENSHIP(S) Coutry{les)7 18. DATE U.S. CITIZENSHIP

N.A. ACQUIRED! W4

"1. PLACE OF ENTRY

13. OCCUPATION

RETIRED

20, COUNTRY

WA.

We#. MN.

RI. DETAILS OF OTHER GOVENMEST SERVICE, U.S. OR FOREIGN JYTELLIGECE
MAVAWA C2gn Duke wend whk Tweeter wee


14-0000

1. FULL NAME (Last-Firat-Middle)
EN yg

4. CAUSE OF DEATH

ITE IOS LRG Ss
£ of time) UNDER WHICH SHE HAS
EVER USED THESE NAMES. IF LEGAL CHANGE, GIVE PARTICULARS (Where
and by what authority). USE EXTRA SPACE PROVIDED ON PAGE 16 OF THIS
FORM TO RECORD THIS INFORMATION,

[\CASaNovAR

6. CURRENT ADDRESS - GIVE LAST ADORESS,

the Gt fenvian hgh fel $7

9. CITIZENSHIP

Cohen

DATE OF ENTRY

hot ffs0

FORMER CITIZENSHIP(S) LCountry(tee)7

W-

New Or lear,

CITIZENSHIP

ELE

18. OCCUPATION 16. PRESENT EMPLOYER (Give last employer,

Hfetsewu KE M8,
EMPLOYER'S BUSINESS ADDRESS OR MOTHER'S BUSINESS ADDRESS IF SELF EMPLOYED

WA.

19, BRANCH OF SERVICE 20. COUNTRY

WA, MA) .
U's

Sp. MAIL) CENSCR 1 NEW COLERYS
CEVSORSHIP OFFICE DakiIngG wenLd WAR IW

13. DATE U.S,

ACQUIRED

if Mother ie deceased or unemployed

DATES OF MILITARY SERVICE (From-and-To)

21. DETAILS OF OTHER GOVERNMENT SERVICE, U.S. OR FOR

SECTION XVI BROTHERS AND SISTERS (Includin,
aD FULL NAME (Laat-F iset-Middle)

(Remkieuex, ARNESTS Tose,
4. CURRENT ADDRESS (No., Street, City, Zone, State, Country)

‘2/2_ MgPE Rd. Metaie Lg. USA.

{. FULL NAME (Last-Firet-Middie) 2. RELATIONSHIP

& Half, Step- and Adopted Brothers and Sisters)

2 RELATIONSHIP 3. CITIZENSHIP (Country)
Bho THER. U.S.
S&S. LIVING &. AGE
[res T [xo] 38

3. CITIZENSHIP (Country)

4. CURRENT ADDRESS (No., Street, City, Zone, State, Country) 8. LIVING
a7

2. RELATIONSHIP 3. CITIZENSHIP (Country)

2. RELATIONSHIP : é
\
2. RELATIONSHIP 3. CITIZENSHIP (Country)

8. LIVING

2. RELATIONSHIP 3. CITIZENSHIP (Country)

5. LIVING

2. RELATIONSHIP 3. CITIZENSHIP (Country)

5. LIVING

/2, RELATIONSHIP 3. CITIZENSHIP (Country)

+ FULL NAME (Last-First-Middle)

4. CURRENT ADDRESS (Wo., Street, City, Zone, State, Country)

1. FULL NAME (Laat-Firat-Middte,

4. CURRENT ADDRESS (No., Street, City, Zone,

State, Country)

1. FULL NAME (Laat-F irs t-Middle)

4. CURRENT ADORESS (No.,

Street, City, Zone, State, Country)

FULL NAME (Laet-First-Middie)

4. CURRENT ADDRESS (No.,

Street, City, Zone, State, Country)

1. FULL NAME (Laet-First-Middle)

‘4. CURRENT ADDRESS (No., Street, City, Zone, State,

ls FULL NAME (Laat-F irat-Middle)

+ CURRENT ADDRESS (No., Strost, City, Zone, State, Country)

-N-

14.90000

-12-

ECTION Xviq FATHER-IN-LAW
ae “FULL NAME (Laat-Firet-Middie) = 2. LIVING 3. DATE OF DEATH 4. CAUSE OF DEATH

“HOSS , SAmuez SANFoRD i | T BI | tunes He?) EART A

'3. STATE OTHER NAMES RE HAS USED INDICATE CIRCUMSTANCES (Including length of time) UNDER WHICH HE HAS

. EVER USED THESE NAMES. IF LEGAL CHANGE, GIVE PARTICULARS (Where
id by what authority). USE EXTRA SPACE PROVIDED ON PAGE 16 OF THIS
AM (wkwaye scarce ChieDW00d) | 2
6. CURRENT OR LAST ADDRESS (No., Street, City, State, Country)

FORM TO RECORD THIS INFORMATION.
‘PReeute 2 Box so EDENTON, W.C.)

] 8. PLACE OF BIRTH (City, State, Country)

“Me Bree) ALABAMA, tt-$.

-S.- DATE OF ENTRY M1. PLACE OF ENTRY

“Sf.

9. CITIZENSHIP

“Y-S-A.

IF BORN OUTSIDE U

FORMER CITIZENSHIP(S) ZCountry(iee)? 13. DATE U.S. CITIZENSHIP 14, WHERE ACQUIRED (City, State, Country)
ACQUIRED :
. . vf . ALA.

1S. OCCUPATION

SIwvyeeR

16. PRESENT EMPLOYER

‘RP BAER

(Give tast employer, If Father-in-Laew is deceased or imemployed)

WD Co, EVEN TON)

3. DATE OF DEATH

LX] ves T [se] m4.

INDICATE CIRCUMSTANCES Cncluding tength of time) UNDER WHICH SHE HAS
EVER USED THESE NAMES. IF LEGAL CHANGE, GIVE PARTICULARS (Whero
and by what authority), USE EXTRA SPACE PROVIDED ON PAGE 16 OF THIS

FORM TO RECORD THIS INFORMATION.

, Street, City, State, Country)
Heute 2, Box Svo, EDEN TON) Me.
ra DATE OF BIRTH 8. PLACE OF BIRTH (City, State, Country)
Dec. BI IF FF’ ZLAKREL |) Mss.

10. IF BORN OUTSIDE U.s. 1t. PLACE OF ENT

RY
MA.
13. DATE Us. CITIZENSHIP

ACQUIRED WA.
16. PRESENT EMPLOYER (Give last employer,
Mt, A.

BLOOD, MARRIAGE OR ADOPTION WHO EITHER QQ) Live ABROAD,
U.S. CITIZENS OR (3) WoRK FOR A FOREIGN GOV ERNMENT

2. RELATIONSHIP

SISTER (W LAW

CaSElWOs FE

RELATIVES BY
SECTION xix . (2) ARE NOT

1 FULL NAME {Last-Firet-Middle)

‘LOPEZ ELEWA

4. ADDRESS OR CO NTRY IN WHICH RELATIVE RESIDES

le P ¢
2/2 Mare RA. Mer
6. CITIZENSHIP (Country) 7. FREQUENCY OF CONTACT 8. DATE OF LAST CONTACT
MEXICAN MCE EARL lyf) DUNE SFE
; ; 2. RELATIONSHIP Peace]
t. FULL NAME (Last-Firat-Middie)

- EMPLOYED By
4. ADDRESS OR COUNTRY IN WHICH RELATIVE RESIDES

7. FREQUENCY OF CONTACT 8. DATE OF LAST CONTACT

2. RELATIONSHIP

5. EMPLOYED By
» DATE OF Last CONTACT

2. RELATIONSHIP . pee]

- EMPLOYED By

6. CITIZENSHIP (Country) 7. FREQUENCY OF CONTACT
'. FULL NAME (Laet-Firet-Middie)
4. ADDRESS OR COUNTRY IN WHICH RELATIVE RESIDES

_————
SECTION XIX CONTINUED TO PAGE 13;


14-0000

SECTION XIX CONTINUED FROM PAGE 12
6. SPECIAL REMARKS, IF ANY, CONCERNING RELATIVES NOTED IN SECTION XIX ABOVE

Above nelalive has bees a Covtewuocuas Resident in the US.8. Sthee (E¢5- 6, Mew

Ppleins 4h,

RELATIVES BY BLOOD, MARRIAGE OR ADOPTION WHO ARE IN THE MILITARY OR CIVI
SECTION XX SERVICE OF THE UNITED STATES .

6. TYPE AND LOCATION sie SERVICE (If Town)

MUAQUNE P/LOT AND (gtr Gane US TRUCTOR
¢ FEASA COCA a FU AL env
2. RELATIONSHIP

4. CITIZENSHIP

6 TYPE AND LOCATION OF SERVICE (If known)

4. CITIZENSHIP
6. TYPE AND LOCATION OF SERVICE (it known)

REFERENCES, ACQUAINTANCES, AND NEIGHBORS
1, LIST FIVE CHARACTER REFERENCES, NOT RELATIVES, IN THE U.S., WHO KNOW YOU INTIMATELY

2. RELATIONSHIP

BUSINESS ADDRESS
(No., Street, City and State)

ADe p
Pesident, dl g

A Mes: WOOD _ “Ss.

BUSINESS ADDRESS
(No., Street, City and State)

RESIDENCE ADDRESS
(No., Street, City and State)

EBASCO SERUICES , MY.
GNk.

COWL SERVICE

- J. BRu NO.
Denorny BeETTCHER)

HEeasS Ew rE

. BUSINESS ADDRESS RESIDENCE ADDRESS
(Last-Firat-Middle) (No., Street, City and State) {(No., Stroot, City and State}

Pec bles en clone ta
mm. é. Pee f Wlw @, A Vew Galen res UF i
RE PRED | S72 pt war Se
7. Whi Le ere, SEANCE News Cale ,
‘THANE UMIVERS ITY
Sowishe Dapnanieny ak.

-13-


14-0000

-4-

‘ e SECTION XXII CLUBS, SOCIETIES, AND OTHER ORGANIZATIONS
. rattle
° NOTE: List names and addresses of all clubs, societies, professional societies, employee groups or organizations of any kind

(Include membership in, or support of, any organization having headquarters or branch in a foreign country) to which you
belong 6r have belonged.

DATES OF MEMBERSHIP

NX
bY
y

AODRESS
NAME AND CHAPTER (Number, Street, City, State, Country)

TULAWE (AM UERSITY

SFS1
4 fe. on .
DE PRUw )UNLVERS TTY

fmenicad Ms. of laces, « ba tush ¢ fa aie tn ke
ee

Ph, S4 MA Lor

e RESIDENCES FOR THE PAST 15 YEARS
ADDRESS - LAST RESIDENCE FIRST

(Number, Street, City, State, Country)

unl /96/

CFS 7


14-0000

a

.
. td
aor *

a)

t

@ | SECTION XXIV : ADDITIONAL INFORMATION
ra -
1. OO YOU ADVOCATE OR HAVE YOU EVER ADVOCATED; OR ARE YOU NOW OR HAVE YOU EVER BEEN A MEMBER OF;
OR HAVE YOU EVER SUPPORTED OR BEEN ASSOCIATED WITH ANY POLITICAL PARTY. INDIVIDUAL OR ORGAN -
IZATION WHICH ADVOCATES OR TEACHES THE OVERTHROW OF THE GOVERNMENT OF THE UNITED STATES BY

FORCE, VIOLENCE OR OTHER UNCONSTITUTIONAL MEANS, OR SEEKS BY FORCE OR VIOLENCE TO DENY PERSONS K\/
THEIR RIGHTS UNDER THE CONSTITUTION OF THE UNITED STATES? . ‘A

2. 1F YOU HAVE ANSWERED “YES” TO THE ABOVE QUESTION, EXPLAIN

N.A.

YES 4. IF SO, TO WHAT EXTENT?
» OVER USED INTOXICANTS?
VER USED TS ol
XT ne Nt
YES 6. IF SO, TO WHAT EXTENT?
5. DO YOU USE OR HAVE YOU
EVER USED NARCOTICS? Sino | N-f-
7. HAVE YOU EVER BEEN A MEMBER OF, OR SUPPORTED, OR HAD ANY CONNECTIONS WITH A FOREIGN INTELLIGENCE ORGAN-
IZATION OR ITS ACTIVITIES? 5 ¢
(ves. [X]No IF ANSWER IS “YES*, GIVE COMPLETE DETAILS.

wh.

8. SEO MENT SINCE NAMES OF GOVERNMENT DEPARTMENTS, AGENCIES OR OFFICES TO WHICH YOU HAVE APPLIED FOR EM-
C.D.A., STATE DEPARTMENT, Pan AME MER Union, Cry SERVICE,

USTA.
9. IF TO YOUR KNOWLEDGE, ANY OF THE ABOVE HAVE CONDUCTED AN INVESTIGATION OF YOU, INDICATE THE NAME OF THE
AGENCY AND THE APPROXIMATE DATE OF THE INVESTIGATION.

UNK.

NOTE SPECIAL| If your answer is “YES* to the following Questions 10, 11 or 12, provide the information requested for each
INSTRUCTIONS | question on a separate, signed sheet and attach the sheet to this form in a sealed envelope. :
| YES

| vee

YES

10. HAVE YOU, OR TO YOUR KNOWLEDGE HAS YOUR SPOUSE, EVER BEEN DETAINED, ARRESTED, INDICTED OR CON-
Weer ANY VIOLATION OF THE LAW OTHER THAN A MINOR TRAFFIC VIOLATION IN THE UNITED STATES OR

IF SO, STATE NAME OF COURT, CITY, STATE, COUNTRY, DATE, NATURE OF OFFENSE AND DISPOSITION OF CASE
IN ACCORDANCE WITH THE SPECIAL INSTRUCTION ABOVE.

><

11. HAVE YOU EVER BEEN ARRESTED, COURT-MARTIALED OR OTHERWISE PUNISHED UNDER MILITARY LAW OR REG-
ULATIONT IF SO, DESCRIBE INCIDENT(S) AND PROVIDE DATE(S) OF OCCURRENCE ON SEPARATE SHEET IN AC-
CORDANCE WITH SPECIAL INSTRUCTIONS ABOVE. s

12. ARE THERE ANY UNFAVORABLE INCIDENTS IN YOUR LIFE, NOT MENTIONED ABOVE, WHICH MAY BE OISCOVEREO
IN SUBSEQUENT INVESTIGATION, WHETHER YOU WERE DIRECTLY INVOLVED OR NOT, WHICH MIGHT REQUIRE EX-
PLANATION? 1F SO, DESCRIBE INCIDENT(S) AND PROVIOE DATE(S) OF OCCURRENCE ON SEPARATE SHEE
CORDANCE WITH SPECIAL INSTRUCTIONS ABOVE.

><] B<
a

@ | SECTION XXV j PERSON TO BE NOTIFIED IN CASE OF EMERGENCY
1. NAME (Firat-Middfe-Last) 2. RELATIONSHIP

 Phukin€ WTuayitA wt rE

3. HOME ADDRESS (No., Street, City, Zone, State, Country)
$360 Sw. (78 St PEARINE S$?) FLA. CEdite~S- §3¢E

BUSINESS ADDRESS (No., Street, Clty, Zone, State, Country) - INDICATE NAME OF FIRM OR|6. BUSINESS PHONE NO. & EXT.
EMPLOYER, IF APPLICASLE

7. IN CASE OF EMERGENCY, OTHER CLOSE RELATIVES (Spouse, Mother, Father) MAY ALSO BE NOTIFIED. IF SUCH NOTIFICATION
iS NOT DESIRABLE, BECAUSE OF HEALTH OR OTHER REASONS, PLEASE SO STATE.

AA.

-15-

14-0000

-16-
@ [SECTION XXVI ° CERTIFICATION
soy
4 YOU ARE INFORMED THAT THE CORRECTNESS OF ANY STATEMENT MADE IN THIS APPLICATION
. WILL BE INVESTIGATED.
oa

4 have read and understand the instructions. | Certify that the foregoing answers are true and correct to the best of m
knowledge and belief. | agree that any misstatement or omission as to material fact will constitute grounds for imme: iate

dismissal or rejection of my application. | also understand that any false statement made herein may be punishable by
faw (U.S. Code, Title 18, Section 1007}.

- DATE OF SIGNATURES
Seth S, [FES

3. SIGNED AT (City and State)

Mihm, FR.

NOTE: Use the following space for extra details. Reference each continued item by section and item n SKich it relates
sign -your name at the end of the added material.
page and sign each such page.

(
If additional space is required use extra pages the same size as this


